Speculum Exam

Are you going to conduct a pelvic exam? Utilize our speculum exam template to help you with exam reminders and recording test results.

By Patricia Buenaventura on Jul 15, 2024.


Fact Checked by Ericka Pingol.

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Speculum Exam PDF Example
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What is a Speculum Exam?

A is one of the exams done during a pelvic exam. During this exam, the doctor in charge uses a speculum, a hinged and duck-billed-shaped device made of metal or plastic, to spread the vaginal wall to see the vagina and cervix better. Aside from aiding in a Pap smear, a test wherein the doctor uses a swab to collect cervix cells to check abnormalities that can lead to cancer, the speculum also helps observe for symptoms of sexually transmitted infections and other health issues.

A speculum’s exam results are written on a clinical note or are usually memorized by the doctor in charge. However, if you’re the doctor assessing your patient and need a document to record your patient results or a guide or reference for a speculum exam, check out our printable speculum exam template.

On our template, you will find the following:

  • Basic information such as the patient’s name, your name, and examination date
  • Reminders before you do a speculum exam
  • Dedicated sections where you can record any observations and be reminded of the samples you took
  • Space where you can write additional notes

How Does it Work?

Step One. Download the Template

Access and download a copy of our printable speculum exam template by doing either of the following:

  • Clicking the “Use this Template” or “Download Template” button above
  • Searching for the “Speculum Exam” in Carepatron’s template library on our website or app

Step Two. Go Over Reminders

Before you conduct the test, complete the required basic information, such as the patient’s name, your name, and the exam date. Then, go over the reminders written on the template and follow the instructions, such as explaining the speculum exam directions to the patient and asking for their consent.

To see if this will prove to be helpful to you or if you would like to make edits, we’ve added the reminders on the template below.

  • Introduce yourself to the patient. Tell them your name and role.
  • Ask for the patient’s name and date of birth for confirmation.
  • Explain why you need a chaperone and how the exam will go in a language they’ll understand. Don’t forget to ask for their verbal consent.
  • Ensure that they’ve passed urine and have told you if they’re experiencing pain or may be pregnant by asking them about either once more.
  • Provide them with as much privacy by allowing them to undress in a separate room and cover themselves with a sheet while lying on the clinical examination couch.
  • Before you begin, reassure them that you can stop immediately if it becomes too uncomfortable for them.

Step Three. Conduct the Test

Once your patient understands what the test entails, it’s time to gather the needed equipment, namely:

  • Speculum
  • Gloves
  • Lubricant
  • Sample Pot
  • Endocervical Brush

For a refresher, here are the instructions for a speculum examination.

  1. Cover the exposed area.
  2. Inspect the vulva for any scars, abnormalities, etc.
  3. Wear gloves.
  4. Lubricate the speculum.
  5. With your non-dominant hand, part the labia, and with your dominant head, gently insert the speculum. The screw must be facing sideways, and the blades must be vertical.
  6. Rotate the speculum 90 degrees or until the screw faces upwards and the blades horizontal.
  7. Tighten the screw to keep the speculum open.
  8. You can swab or do a Pipelle biopsy to collect cell samples with your dominant hand.

Step Four. Record the Results

After you conduct the test and ask the patient to dress up, you can record any abnormalities you observed or, if none, tick your chosen process/es of collecting samples. Feel free to write down any additional notes in the space provided.

When Would You Use this Template?

Practitioners can use this template whenever they need to conduct a pelvic exam, specifically a pap smear or a speculum exam. To know if you must recommend conducting a speculum exam on your patient, you must check if they have symptoms or have a high risk of developing diseases or disorders. 

To help you out, we’ve listed instances when you have to prepare a copy of a speculum exam template:

  • Abnormal bleeding/vaginal discharge
  • Pain in the pelvis or during sex
  • Before or while getting an intrauterine device (IUD) or endometrial biopsy
  • During the patient’s first prenatal care visit
  • If the patient has a family history of ovarian/cervical cancer and gynecological conditions or if they are concerned that they’ve contracted an STD


Early Recognition and Prevention

You can immediately conduct the test with a template when the patient consents. You won’t have to rush searching for reminders or what to look for in their cervix because all the needed information is on the template. As a result, you can conduct the test earlier, detect if there are any problems, and prevent the worsening of the patient’s condition.

Improves Monitoring

If the patient requires frequent pap smears and cervical exams, you can use the template as a document to compare with to check the progress of the medication or treatment. To add, if you’re teaching a less experienced doctor how to do the exam, you can use it as a guide to monitor if they are conducting the assessment correctly.

Written Copies of Results

Having a written copy of results reduces the risk of you forgetting your findings and can be more easily shared with other practitioners who may want to use it as a reference.

Fully Digital

Since our free speculum exam template is fully digital, it can be edited on any local PDF editor you have or on Carepatron. Even better, you can store it on Carepatron to keep an easily accessible copy for fellow practitioners caring for the same patient.

Research and Evidence

According to the American College of Obstetricians and Gynecologists, pelvic exams are recommended only when they have symptoms or are at risk due to their medical history It’s usefulness for asymptomatic women, women who aren’t pregnant, or those who aren’t at risk of developing any conditions are yet to be researched. Therefore, regarding the speculum exam, it still proves to be useful, but only in situations when conducting a pelvic exam is beneficial to the patient. 


Pelvic Exams. (2023). Retrieved 2 June 2023, from https://www.acog.org/womens-health/faqs/pelvic-exams#:~:text=The%20American%20College%20of%20Obstetricians,should%20make%20this%20decision%20together.

Who uses Speculum Exams?
Who uses Speculum Exams?

Commonly asked questions

Who uses Speculum Exams?

Health care professionals such as obstetrician-gynecologists are the ones who may benefit from our speculum exam template the most.

When do you use Speculum Exams?

You use the speculum exam template for a pelvic exam or pap smear. For specific instances when you must conduct this assessment, refer to the “When Would You Use this Template?” section above.

What does a Speculum Exam assess?

It assesses a patient’s vagina and cervix to check if there are any abnormalities that can lead to complications or conditions.

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